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FOR OFFICE USE: -� --------------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. . G7___._ .. -- -- -- (Complete in Duplicate) Date issued ____lv��._ a --------------------:. ------------------------..._ This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. -----------I------------------- JOB ADDRESS AND LOCATION----- x -----------�Q-x------K;k 2---------------------7 t Owner's Name---M-Y-•'------ ---D...- ��n,-------- -;''+ �-------- -----'--------%------ r I Phones 2- Address------------•-------- ------------------------------------------------------------------- ------------------------------ •---------------•-•-------------•- Contractor's Name----- ------------------- _J�__. _ ..I __ [ G ----- ----�--�-t"---f--�---`�---------�-----�� -------- ._�'---� h..�..:--------�---------�------ Phone...�-�-a2--�--�io----- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --j----- Number of bedrooms -,:3--- Number of baths __]----- Lot size ---------I------ —-------------------- Water Supply: Public system ❑ Community system ❑ Private VDepfh to Water Table 5-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam lay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date---------- ---------) No New Construction: Yes ❑ No R' FHA/VA: Yes ❑ No�'� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--------------- Distance from foundation--------------------Material .__-_-_-___---_----.____.-.-----__.-..._-._--. ❑ No. of compartments--------------------------Size------------------------•-------Liquid depth--------------------------Capacity----------------------- Disposal Field: r Distance from nearest well....Q.{_._._Distance from foundation-------L_D........Distance to nearest lot line____ Number of lines-------------- -------------- Length of each line-----------1- -------------Width of trench-------------, - Type of filter material___ Q_er-K -.Depth of filter material--------�_B_i------ Total length---------------------- ------- eepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line-_---..-_.-_____ ❑ ' t Number of pits----------------------Lining material--------------,---------Size: Diameter------------- - ------ Depth--- .-.-----------.-----------.-- S3 Cesspool: Distance from nearest well_---------------Distance from foundation----- -------------.Lining material.._.--.__-.---__-__._..-.__-----_--- [� Size: Diameter- Depth - ------•--- Liquid Capacity gals. Privy: Distance from nearest well------_-----------------------------------------Distance .from nearest building_----------_-------_---_----________._._. ❑ Distance to nearest lot line-----------------------------------------------------------------------•------------------------ --------------- ------------- ---------- �/J e Remodeling and/or repairing (describe) A-`-��---4o------ �--------- ------------------•-------------------------- 0 ---------------•-------------•------------------------------------•------•---------------------------=--------------------------------------------------------- ------------------ ----------------------------------------------•----------------------•-------------- ----------------------------------------------------------------------- --------------------------------------------------------- ---------------------- -------------- ---------------•-------------------------------------------------------------- -------------------------------------------------------- -------------------- -------- H I hereby certify that I have. prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed), = -- '-- ----- --- "_..(Ow er and/or Contractor) H BY: --- ------- ----- ------= (Title}. --t-------- -- - ----------------- (Plot plan, showing size of lot, location o sys+em in relation to wells, buildings, a+c., can.be placed on reverse side]. FOR DEPARTMENT USE ONLY s APPLICATION ACCEPTED BY - DATE --------------------------------- REVIEWED - { REVIEWEDBY--------------------------- --------------------------------------------- <�_... DATE--------- i . .�.. a BUILDING PERMIT ISSUED = - --- -------- ------------- DATE----------------------------- ------------- --- ----------- Alterations and/or recommendations---------------_-- { -'--------------------------------- ---------------------------- -------------- -••---------- S ---•-----------------------------•-------------------------------------------------------------------- ---------- ----------------------------------------------------- ----------------------------- ---------------- a FINAL INSPECTION BY:----- - -- - ----- - -- - •----�---- - � Date - --------- ----• - - --- - - ' -------------------'--------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVtSEO S-59 3m 3-'63 F'.P.CO. - 1�